Chest
Volume 146, Issue 2, August 2014, Pages 267-275
Journal home page for Chest

Original Research
Critical Care
Inappropriate Care in European ICUs: Confronting Views From Nurses and Junior and Senior Physicians

https://doi.org/10.1378/chest.14-0256Get rights and content

BACKGROUND

ICU care providers often feel that the care given to a patient may be inconsistent with their professional knowledge or beliefs. This study aimed to assess differences in, and reasons for, perceived inappropriate care (PIC) across ICU care providers with varying levels of decision-making power.

METHODS

We present subsequent analysis from the Appropricus Study, a cross-sectional study conducted on May 11, 2010, which included 1,218 nurses and 180 junior and 227 senior physicians in 82 European adult ICUs. The study was designed to evaluate PIC. The current study focuses on differences across health-care providers regarding the reasons for PIC in real patient situations.

RESULTS

By multivariate analysis, nurses were found to have higher PIC rates compared with senior and junior physicians. However, nurses and senior physicians were more distressed by perceived disproportionate care than were junior physicians (33%, 25%, and 9%, respectively; P = .026). A perceived mismatch between level of care and prognosis (mostly excessive care) was the most common cause of PIC. The main reasons for PIC were prognostic uncertainty among physicians, poor team and family communication, the fact that no one was taking the initiative to challenge the inappropriateness of care, and financial incentives to provide excessive care among nurses. Senior physicians, compared with nurses and junior physicians, more frequently reported pressure from the referring physician as a reason. Family-related factors were reported by similar proportions of participants in the three groups.

CONCLUSIONS

ICU care providers agree that excessive care is a true issue in the ICU. However, they differ in the reasons for the PIC, reflecting the roles each caregiver has in the ICU. Nurses charge physicians with a lack of initiative and poor communication, whereas physicians more often ascribe prognostic uncertainty. Teaching ICU physicians to deal with prognostic uncertainty in more adequate ways and to promote ethical discussions in their teams may be pivotal to improving moral distress and the quality of patient care.

Section snippets

Study Design and Procedure

We conducted a cross-sectional study among nurses (defined as registered nurses, including head nurses and also including, in France, nursing assistants), junior physicians (defined as physicians in training), and senior physicians (including heads of ICUs) in European adult ICUs on a single day (Tuesday, May 11, 2010, at 8:00 am to Wednesday, May 12, 2010, at 8:00 am).11

Instruments

Each care provider working in the ICU on the day of the survey completed a questionnaire regarding personal characteristics

Participants and ICUs

Of the 1,651 staff members of 82 ICUs who completed the participant questionnaire and filled out the perceived inappropriate care question, 1,218 were nurses, 180 were junior physicians, and 227 were senior physicians; 26 failed to indicate their job titles. Basic demographic characteristics of the participating clinicians are given in Table 1. Participation rates, ICU characteristics, and participant characteristics are described in more detail in a previous article.11

In all, ICU clinicians

Discussion

We found that ICU care providers throughout Europe more or less agree on what the main issues of inappropriate care are. Nurses and junior and senior physicians indicate that a mismatch between level of care and prognosis (disproportionate care) is the most common cause of inappropriate care in the ICU. Remarkably, factors inside the ICU were the most important reasons for perceived disproportionate care. This perceived disproportionate care was more often ascribed to prognostic uncertainty by

Conclusions

In conclusion, ICU care providers feel that excessive care is a true issue in their daily ICU practice. Nurses charge physicians with a lack of initiative and poor communication, whereas physicians more often ascribe prognostic uncertainty as a reason as to why disproportionate care is continued. These are important targets for efforts to improve care for patients and working environments for clinicians.

Acknowledgments

Author contributions: As a principal investigator, R. D. P. had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. R. D. P., E. A., B. R., F. D. G., J. D., and D. D. B. contributed to the study concept and design; R. D. P. and D. D. B. contributed to the design of the questionnaire; R. D. P., E. A., B. R., F. D. G., A. Max, A. Michalsen, P. A. M., R. O., F. R., J. D., and D. D. B. contributed to coordination of

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These data were presented at the 12th European Association for Palliative Care Congress, May 18-21, 2011, Lisbon, Portugal, and at the 24th European Society of Intensive Care Medicine Annual Congress, October 1-5, 2011, Berlin, Germany.

FUNDING/SUPPORT: This study was supported by a European Society of Intensive Care Medicine/European Critical Care Research Network award (iMDsoft Patient Safety Research Award, 10,000 €, Vienna 2009).

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

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